Skin cancers are increasing in incidence and are ranked third among all cancers [1, 15]. They are among the most common in the West [1, 15, 16]. In Australia, skin cancers have the highest incidence in the world with 33.6 cases / 100,000 population [16]. This high frequency in the West contrasts with their relative rarity in Africa. Indeed, skin cancers represent 7.5–11.8% of all cancers in Africa [4, 17]. Skin cancers, although regularly diagnosed in Burkina Faso, remain relatively rare compared to the European and American literature [7]. Despite their low frequency, these cancers present difficulties in their management. Indeed, their diagnosis is late due to long delays in consultation (13.6 months) and consequently tumour sizes are large with an average of 9 cm. This contrasts with the small tumour sizes noted by some authors in developed countries, which range from 0.4 cm to 2 cm [8, 10]. When the tumour is small, direct excision-suture is possible [18]. However, when the tumour is large, the resection leaves large defects that can be filled by several procedures [16, 19]. There are many indications for skin coverage, including post-traumatic skin defects, surgical excision for benign or malignant tumours, burns, and deformities [18]. Skin coverage after large tumour resections remain a real challenge for healing. Direct suturing helped by the intrinsic elasticity and plasticity of the skin is no more possible [18, 19]. The prerequisite for direct suturing is an early diagnosis with small resections. This is far from being the case in our series where the average size of the tumours was 9 cm. Several methods of skin coverage must therefore be used [18, 19]. Pedicle flaps are used to fill in surgical defects [19]. Local skin or musculocutaneous T- and H-shaped flaps are used to treat skin defects in the forehead [20]. Rhombic flaps, which are local transposition flaps, are used to fill defects after skin cancer surgery in the head and neck region [19]. Z-plasty is the most commonly used technique in precarious situations and has solved 58.3% of the skin coverage problems of the trunk and limbs in our series. In addition to the size of the tumour, the indications for Z-plasty in our series were the absence of superinfection of the tumour, the absence of bony relief making it difficult to mobilise the flaps, and the localisation of the tumour in an area where flaps can be mobilised. The size of the mobilised flaps remains function of the width of the surgical wound [18, 20]. However, for vitality of the flaps in the Z-plasty that are free, non-pediculised flaps, we followed the 2:1 rule, meaning the length should not be more than twice the width.
In a situation of limited resources, diagnostic delays, poor results and inaccessibility of chemotherapy, and the absence of radiotherapy give surgery a central place in the management of skin cancers. In case of large tumour sizes, the surgeon has the choice between directed healing and mobilisation of skin flaps or skin grafts [19]. Z-plasty was performed in 58.3% of our patients with tumours size between 5 and 20 cm. Z-plasty allowed skin closure after large skin resections. Unlike vascularised flaps, it does not require a great technical skill, is fast to perform and accessible to most surgeons. The average healing time after Z-plasty was 15 days. Min and col. in their series found 29 days [13]. In our series, this healing time is 4 times longer in secondary healing. In addition, with an average of two wound dressings per week, it makes the total number of wound dressings to be 5 times higher in secondary wound healing than in Z-plasty.
The flap does not increase the recurrence rate, nor does it interfere with other adjuvant oncological treatments [19, 20]. The advantages of Z-plasty over secondary wound healing and skin grafting are short healing times and low postoperative care costs. Z-plasty thus seems to us to be a technique of choice in precarious situations for low-income countries such as Burkina Faso. In our series, the Z-plasty proved to be practicable, simple to perform and with very few complications. The healing time was short compared to secondary healing. It therefore reduces the number of dressings, trips to health centres, and the cost of care. These skin oncoplasties also reduce the rate of recurrence because of the large resections they allow the surgeon to perform without having to worry about compromising skin closure.